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October 2014 VOL 5, NO 5
Navigation as a Tool for Quality Improvement
Sharon S. Gentry, RN, MSN, CBCN
The National Comprehensive Cancer Network (NCCN) provides clinical practice guidelines in oncology for all types and stages of cancer as well as areas of supportive care. The guidelines are updated annually and allow new findings to be initiated quickly. They have become a benchmark as the best standard of care in the United States and internationally. Concordance of care is provided in an annual report for each participating institution. One hundred percent is not expected since the clinical situations involve the human nature of disease—comorbidities, patient choices, and cultural values. Beyond treatment care, there was a lot of variation in practice patterns. The variation in care among the centers drove the NCCN to initiate Opportunities for Improvement. Breast cancer care was chosen as the project for institutions to identify and address quality issues. Some chose process-oriented projects while others selected guideline-targeted practices. Interestingly, navigation was used as a tool in 3 of the opportunities.
Northwestern University used nurse navigators to assist in coordinating the multidisciplinary evaluation in a timely fashion. Two navigators were hired to make sure any imaging from outside institutions would be reviewed internally within 3 days of receiving the images, and to efficiently schedule any additional workup that was required. Once surgery scheduling was completed, postoperative appointments with the surgeon, medical oncologist, and radiation oncologist were also scheduled. This allowed the patient to receive the recommended adjuvant therapy within a 120-day window. The systemic review and use of nurse navigators allowed timely care from diagnosis through treatment.
Fox Chase Cancer Center redesigned their patient access for new patient intake. In the preimprovement design, a nonclinical scheduler transferred patients to a preregistration line to leave messages. Registration was inconsistently completed before the initial visit. In the improved design, a nurse navigator performs the intake and then hands the patient off to real-time registration/insurance verification by nonclinical staff. Nurse navigators are connected with the new patients within 24 hours after a visit request. Preregistration is now consistent prior to the first visit and benefits are verified. Also, with the nurse navigator’s clinical expertise, the patient is scheduled for the appropriate type of appointment. The patient is educated about the visit, as well as informed regarding what to bring with him or her or send before the visit. Education from the navigator allows the patient to understand why this information is important to his or her clinical visit and decision-making. The navigators identify and remove barriers to timely cancer treatment. They also meet the patient in person upon arrival for the consult. The use of navigation has led to a 74% retention rate after the first visit, and the time from call to first appointment has been reduced from 14 to 21 days to 7 days. Future opportunities are being visualized as risk assessment and clinical trials plan to be integrated with the program.
Roswell Park Cancer Institute focused on patient satisfaction and wait times. From their analysis, a Patient and Family Advisory Council was formed to help address patient access and intake concerns. Lack of communication and misunderstanding of the time associated with a new patient visit led to the establishment of a patient navigation program. Using existing resources, the educators in the patient resource center contact each new breast cancer patient before the first visit. The patient is contacted 5 or more times through the primary treatment phase, and the final contact is 2 to 3 months after completion of therapy (early survivorship phase). Patient experience improvement was shown with a 40% decrease in complaints and a 10-point increase in patient satisfaction scores.
Congratulations to each of these programs, as well as others that will be used as a model to improve care and the patient experience. The use of nurse navigation as well as nonclinical navigation will contribute to the future trend of quality reporting and value-based reimbursement.